What is the management for a patient with bleeding esophageal varices likely due to underlying liver cirrhosis?

Management of Bleeding Esophageal Varices

Bleeding esophageal varices require immediate combined pharmacological and endoscopic therapy, with vasoactive drugs started immediately upon suspicion, prophylactic antibiotics within admission, restrictive transfusion targeting hemoglobin 7-9 g/dL, and endoscopic variceal ligation performed within 12 hours of presentation. 1, 2, 3

Immediate Resuscitation (Before Endoscopy)

Hemodynamic Management

• Establish large-bore IV access and implement restrictive transfusion strategy targeting hemoglobin 7-9 g/dL (not 8 g/dL as older guidelines suggested), as aggressive transfusion increases portal pressure and worsens outcomes 1, 2, 3
• Avoid over-resuscitation which can increase portal pressure and precipitate rebleeding 3

Pharmacological Therapy (Start Immediately)

• Initiate vasoactive drugs as soon as variceal bleeding is suspected, before endoscopy confirmation 1, 2, 3
• Options include:
  • Octreotide: 50 µg IV bolus, then 50 µg/hour continuous infusion 3
  • Somatostatin or analogues (octreotide, vapreotide) 1, 2
  • Terlipressin: 2 mg IV every 4 hours 3
• Continue vasoactive therapy for 3-5 days after diagnosis confirmation 1, 2

Antibiotic Prophylaxis (Mandatory)

• Start prophylactic antibiotics immediately in all patients with cirrhosis and GI hemorrhage 1, 2, 3
• First-line: Ceftriaxone 1 g IV every 24 hours (preferred in advanced cirrhosis and centers with quinolone-resistant organisms) 1, 3
• Alternative: Norfloxacin 400 mg PO twice daily or IV ciprofloxacin if oral route not possible 1
• Duration: Maximum 7 days 1
• Rationale: Reduces bacterial infections, improves bleeding control, and decreases mortality 3

Endoscopic Management

Timing and Technique

• Perform endoscopy within 12 hours once hemodynamically stabilized 1, 2, 3
• Endoscopic variceal ligation (EVL) is the first-line endoscopic treatment, achieving hemostasis in approximately 90% of cases 1, 3
• EVL is superior to sclerotherapy with fewer complications 1
• Combined EVL plus vasoactive drugs is superior to either therapy alone, reducing very early rebleeding and treatment failure 3

Post-Endoscopic Care

• Consider proton pump inhibitors (PPIs) after EVL to reduce post-ligation ulcer size and bleeding risk 1, 2
• Repeat EVL sessions every 7-14 days (or 2-8 weeks per some protocols) until variceal obliteration, typically requiring 2-4 sessions 1

Rescue Therapies for Treatment Failure

Definition of Treatment Failure

Treatment failure occurs when there is: 1

• Inability to achieve hemostasis within specific time from start of treatment
• Development of hypovolemic shock
• 3 g drop in hemoglobin within 24 hours without transfusion

Rescue Options (in order of preference)

1. Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• TIPS is the definitive rescue treatment for patients with inadequate bleeding control despite combined pharmacological and endoscopic therapy 1, 3
• Achieves hemostasis in 90-100% of rescue cases 1, 3
• Early TIPS placement (within 24-72 hours, ideally <24 hours) should be considered in high-risk patients: 1, 3
  • Child-Pugh class C (<14 points)
  • Child-Pugh class B with active bleeding
  • HVPG ≥20 mmHg
• Caveat: TIPS carries 15-25% risk of hepatic encephalopathy 3

2. Balloon Tamponade (Temporary Bridge Only)

• Use only as a temporizing measure for maximum 24 hours in patients with uncontrollable bleeding while arranging definitive therapy 1, 3
• Achieves hemostasis in 80-90% but rebleeding rate after deflation is approximately 50% 1
• High risk of serious complications: esophageal ulceration, rupture, aspiration pneumonia 1

3. Self-Expandable Esophageal Metal Stents

• Alternative to balloon tamponade with better bleeding control (85% vs 47%) and fewer serious adverse events (15% vs 47%) 1
• Can remain in place up to 2 weeks 1
• Placed endoscopically without radiological guidance 1

Special Considerations for Gastric Varices

GOV1 (Lesser Curvature Extension)

• Manage identically to esophageal varices with EVL as first-line therapy 1, 3

GOV2 and IGV1 (Fundal Varices)

• Endoscopic variceal obturation (EVO) with cyanoacrylate is first-line treatment for fundal varices 1, 2, 3
• Cyanoacrylate is superior to EVL with significantly lower rebleeding rates (23% vs 47%) 1, 3
• Alternative rescue options: TIPS (90-100% hemostasis) or balloon-occluded retrograde transvenous obliteration (BRTO/PARTO) with >90% hemostasis rates 1, 3

Prevention of Rebleeding (Secondary Prophylaxis)

• Combination of EVL plus non-selective beta-blockers (NSBBs) is the preferred strategy for preventing rebleeding 1
• This combination reduces overall rebleeding (RR 0.44) and tends to decrease mortality compared to EVL alone 1
• Continue surveillance endoscopy every 3-6 months after variceal eradication to detect recurrence 1

Common Pitfalls to Avoid

• Do not delay vasoactive drugs waiting for endoscopy - start immediately upon suspicion 1, 2, 3
• Avoid over-transfusion - target hemoglobin 7-9 g/dL, not higher 1, 2, 3
• Do not omit antibiotic prophylaxis - it is mandatory and improves outcomes 1, 2, 3
• Do not use balloon tamponade for >24 hours due to high complication rates 1
• Do not use sclerotherapy if EVL is available - EVL has superior outcomes 1, 3